Healthcare Provider Details

I. General information

NPI: 1114146420
Provider Name (Legal Business Name): DE-VINE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 E REDD RD
EL PASO TX
79912-7264
US

IV. Provider business mailing address

840 E REDD RD BLDG #1A
EL PASO TX
79912-7264
US

V. Phone/Fax

Practice location:
  • Phone: 915-845-7600
  • Fax: 915-845-7601
Mailing address:
  • Phone: 915-845-7600
  • Fax: 915-845-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25508
License Number StateTX

VIII. Authorized Official

Name: IFEYINWA E
Title or Position: OWNER/PRESIDENT
Credential: RPH
Phone: 915-845-7600